Managed care organizations (MCOs) have been one response to the health care cost-containment dilemma. Recent research on acute stroke patients has shown that managed care patients had a lower probability of receiving in-hospital specialty care than patients in fee-for-service (FFS), but only among older patients. This age gradient raises a contentious issue: the possibility of age-based rationing in MCOs. Follow-up research on such findings is crucial as discussions of managed care resource management strategies become increasingly polarized. As the health care market evolves it is important to update our understanding of how MCOs manage care, especially for the most vulnerable populations. However, for acute stroke patients, much of the management goes on at the hospital level. The long-term objective of this project is to examine the contribution of both MCO incentives and hospital characteristics in explaining variation in specialty care use (including the age gradient), outcomes, and costs for older patients who are hospitalized with acute stroke. The proposed research will identify Medicare beneficiaries 65 years of age and older discharged with acute ischemic stroke during 1997-2000 using claims data from health plans that are part of a large national MCO, and a comparison sample of FFS Medicare beneficiaries from the same metropolitan areas. Administrative data will be used to obtain information on specific MCO incentives, including hospital and physician payment policies, hospital networks, and utilization review. This will be augmented by data on hospital characteristics from the American Hospital Association annual surveys, including the hospital's level of specialization and experience with managed care. Information on the local environment will be obtained from the Area Resource File. Multilevel modeling techniques will be used to separate the effects of MCOs, hospitals and patients in explaining variation in specialty care use, costs and outcomes. The proposed research will provide valuable information to clinicians, policymakers and researchers interested in the effects of managed care and health care providers (i.e., hospitals) on acutely-ill older patients.